Familial hypercholesterolaemia in children and adolescents from 48 countries: a cross-sectional study

BACKGROUND

Approximately 450 000 children are born with familial hypercholesterolaemia worldwide every year, yet only 2·1% of adults with familial hypercholesterolaemia were diagnosed before age 18 years via current diagnostic approaches, which are derived from observations in adults. We aimed to characterise children and adolescents with heterozygous familial hypercholesterolaemia (HeFH) and understand current approaches to the identification and management of familial hypercholesterolaemia to inform future public health strategies.

METHODS

For this cross-sectional study, we assessed children and adolescents younger than 18 years with a clinical or genetic diagnosis of HeFH at the time of entry into the Familial Hypercholesterolaemia Studies Collaboration (FHSC) registry between Oct 1, 2015, and Jan 31, 2021. Data in the registry were collected from 55 regional or national registries in 48 countries. Diagnoses relying on self-reported history of familial hypercholesterolaemia and suspected secondary hypercholesterolaemia were excluded from the registry; people with untreated LDL cholesterol (LDL-C) of at least 13·0 mmol/L were excluded from this study. Data were assessed overall and by WHO region, World Bank country income status, age, diagnostic criteria, and index-case status. The main outcome of this study was to assess current identification and management of children and adolescents with familial hypercholesterolaemia.

FINDINGS

Of 63 093 individuals in the FHSC registry, 11 848 (18·8%) were children or adolescents younger than 18 years with HeFH and were included in this study; 5756 (50·2%) of 11 476 included individuals were female and 5720 (49·8%) were male. Sex data were missing for 372 (3·1%) of 11 848 individuals. Median age at registry entry was 9·6 years (IQR 5·8-13·2). 10 099 (89·9%) of 11 235 included individuals had a final genetically confirmed diagnosis of familial hypercholesterolaemia and 1136 (10·1%) had a clinical diagnosis. Genetically confirmed diagnosis data or clinical diagnosis data were missing for 613 (5·2%) of 11 848 individuals. Genetic diagnosis was more common in children and adolescents from high-income countries (9427 [92·4%] of 10 202) than in children and adolescents from non-high-income countries (199 [48·0%] of 415). 3414 (31·6%) of 10 804 children or adolescents were index cases. Familial-hypercholesterolaemia-related physical signs, cardiovascular risk factors, and cardiovascular disease were uncommon, but were more common in non-high-income countries. 7557 (72·4%) of 10 428 included children or adolescents were not taking lipid-lowering medication (LLM) and had a median LDL-C of 5·00 mmol/L (IQR 4·05-6·08). Compared with genetic diagnosis, the use of unadapted clinical criteria intended for use in adults and reliant on more extreme phenotypes could result in 50-75% of children and adolescents with familial hypercholesterolaemia not being identified.

INTERPRETATION

Clinical characteristics observed in adults with familial hypercholesterolaemia are uncommon in children and adolescents with familial hypercholesterolaemia, hence detection in this age group relies on measurement of LDL-C and genetic confirmation. Where genetic testing is unavailable, increased availability and use of LDL-C measurements in the first few years of life could help reduce the current gap between prevalence and detection, enabling increased use of combination LLM to reach recommended LDL-C targets early in life.

FUNDING

Pfizer, Amgen, Merck Sharp & Dohme, Sanofi-Aventis, Daiichi Sankyo, and Regeneron.

The association between daily step count and all-cause and cardiovascular mortality: a meta-analysis

AIMS

There is good evidence showing that inactivity and walking minimal steps/day increase the risk of cardiovascular (CV) disease and general ill-health. The optimal number of steps and their role in health is, however, still unclear. Therefore, in this meta-analysis, we aimed to evaluate the relationship between step count and all-cause mortality and CV mortality.

METHODS AND RESULTS

We systematically searched relevant electronic databases from inception until 12 June 2022. The main endpoints were all-cause mortality and CV mortality. An inverse-variance weighted random-effects model was used to calculate the number of steps/day and mortality. Seventeen cohort studies with a total of 226 889 participants (generally healthy or patients at CV risk) with a median follow-up 7.1 years were included in the meta-analysis. A 1000-step increment was associated with a 15% decreased risk of all-cause mortality [hazard ratio (HR) 0.85; 95% confidence interval (CI) 0.81-0.91; P < 0.001], while a 500-step increment was associated with a 7% decrease in CV mortality (HR 0.93; 95% CI 0.91-0.95; P < 0.001). Compared with the reference quartile with median steps/day 3867 (2500-6675), the Quartile 1 (Q1, median steps: 5537), Quartile 2 (Q2, median steps 7370), and Quartile 3 (Q3, median steps 11 529) were associated with lower risk for all-cause mortality (48, 55, and 67%, respectively; P < 0.05, for all). Similarly, compared with the lowest quartile of steps/day used as reference [median steps 2337, interquartile range 1596-4000), higher quartiles of steps/day (Q1 = 3982, Q2 = 6661, and Q3 = 10 413) were linearly associated with a reduced risk of CV mortality (16, 49, and 77%; P < 0.05, for all). Using a restricted cubic splines model, we observed a nonlinear dose-response association between step count and all-cause and CV mortality (Pnonlineraly < 0.001, for both) with a progressively lower risk of mortality with an increased step count.

CONCLUSION

This meta-analysis demonstrates a significant inverse association between daily step count and all-cause mortality and CV mortality with more the better over the cut-off point of 3867 steps/day for all-cause mortality and only 2337 steps for CV mortality.

A case of pregnant patient with stenotic bicuspid aortic valve

Key Clinical Message

Asymptomatic severe aortic stenosis (AS) during pregnancy remains challenging; however, the postponement of surgery with the possibility of valvuloplasty as a bridge therapy seems reasonable. Our case showed that despite physiological changes during pregnancy, the aortic valve defect did not worsen, which allowed us to avoid dilemmas related to anticoagulation on artificial valve.

Abstract

A 31-year-old woman, with a bicuspid aortic aorta, post-aortic valvulotomy, was listed for cardiac surgery because of severe aortic stenosis. However, the operation was postponed due to procreation plans. During the pregnancy and delivery, we did not observe neither deterioration of symptoms nor changes of echocardiographic parameters. Subsequent monthly echocardiographic studies did not reveal a significant increase of peak and mean aortic gradient.Presented case reports showed that despite physiological changes associated with pregnancy, the aortic valve defect did not worsen, which allowed to avoid dilemmas related to anticoagulation on artificial valves.

Prevention of cardiovascular disease in young adults: Focus on gender differences. A collaborative review from the EAS Young Fellows

A steady rise in cardiovascular morbidity and mortality has been observed in young adults within the last decades. This trend corresponds to an increasing prevalence of traditional cardiovascular risk factors such as obesity and diabetes mellitus type 2 among young adults living in developed countries. Moreover, age-specific risk factors, such as substance abuse, contraceptive medication, and pregnancy-related diseases also correlate with an increased incidence of cardiovascular diseases. In this review, we discuss the available data for young adults on the epidemiology and the rationale for the causality of traditional and newly emerging risk factors of atherosclerotic cardiovascular diseases. We focus on gender-related differences in the exposure to these risk factors, investigate the recent data regarding screening and risk stratification in the young adult population, and describe the current state of the art on lifestyle and therapeutic intervention strategies in the primary prevention setting.

Intensive Statin Therapy Versus Upfront Combination Therapy of Statin and Ezetimibe in Patients With Acute Coronary Syndrome: A Propensity Score Matching Analysis Based on the PL-ACS Data

Background We aimed to compare statin monotherapy and upfront combination therapy of statin and ezetimibe in patients with acute coronary syndromes (ACSs). Methods and Results The study included consecutive patients with ACS included in the PL-ACS (Polish Registry of Acute Coronary Syndromes), which is a national, multicenter, ongoing, prospective observational registry that is mandatory for patients with ACS hospitalized in Poland. Data were matched using the Mahalanobis distance within propensity score matching calipers. Multivariable stepwise logistic regression analysis, including all variables, was next used in propensity score matching analysis. Finally, 38 023 consecutive patients with ACS who were discharged alive were included in the analysis. After propensity score matching, 2 groups were analyzed: statin monotherapy (atorvastatin or rosuvastatin; n=768) and upfront combination therapy of statin and ezetimibe (n=768 patients). The difference in mortality between groups was significant during the follow-up and was present at 1 (5.9% versus 3.5%; P=0.041), 2 (7.8% versus 4.3%; P=0.019), and 3 (10.2% versus 5.5%; P=0.024) years of follow-up in favor of the upfront combination therapy, as well as for the overall period. For the treatment, rosuvastatin significantly improved prognosis compared with atorvastatin (odds ratio [OR], 0.790 [95% CI, 0.732-0.853]). Upfront combination therapy was associated with a significant reduction of all-cause mortality in comparison with statin monotherapy (OR, 0.526 [95% CI, 0.378-0.733]), with absolute risk reduction of 4.7% after 3 years (number needed to treat=21). Conclusions The upfront combination lipid-lowering therapy is superior to statin monotherapy for all-cause mortality in patients with ACS. These results suggest that in high-risk patients, such an approach, rather than a stepwise therapy approach, should be recommended.

Regional differences in physicians' behavior and factors influencing the intensity of PCSK9 inhibitor therapy with alirocumab: a subanalysis of the ODYSSEY APPRISE study

Background

Despite better accessibility of the effective lipid-lowering therapies, only about 20% of patients at very high cardiovascular risk achieve the low-density lipoprotein cholesterol (LDL-C) goals. There is a large disparity between European countries with worse results observed for the Central and Eastern Europe (CEE) patients. One of the main reasons for this ineffectiveness is therapeutic inertia related to the limited access to appropriate therapy and suitable dosage intensity. Thus, we aimed to compare the differences in physicians' therapeutic decisions on alirocumab dose selection, and factors affecting these in CEE countries vs. other countries included in the ODYSSEY APPRISE study.

Methods

ODYSSEY APPRISE was a prospective, single-arm, phase 3b open-label (≥12 weeks to ≤30 months) study with alirocumab. Patients received 75 or 150 mg of alirocumab every 2 weeks, with dose adjustment during the study based on physician's judgment. The CEE group in the study included Czechia, Greece, Hungary, Poland, Romania, Slovakia, and Slovenia, which we compared with the other nine European countries (Austria, Belgium, Denmark, Finland, France, Germany, Italy, Spain, and Switzerland) plus Canada.

Results

A total of 921 patients on alirocumab were involved [modified intention-to-treat (mITT) analysis], including 114 (12.4%) subjects from CEE countries. Therapy in CEE vs. other countries was numerically more frequently started with lower alirocumab dose (75 mg) at the first visit (74.6 vs. 68%, p = 0.16). Since week 36, the higher dose was predominantly used in CEE patients (150 mg dose in 51.6% patients), which was maintained by the end of the study. Altogether, alirocumab dose was significantly more often increased by CEE physicians (54.1 vs. 39.9%, p = 0.013). Therefore, more patients achieved LDL-C goal at the end of the study (<55 mg/dl/1.4 mmol/L and 50% reduction of LDL-C: 32.5% vs. 28.8%). The only factor significantly influencing the decision on dose of alirocumab was LDL-C level for both countries' groups (CEE: 199.2 vs. 175.3 mg/dl; p = 0.019; other: 205.9 vs. 171.6 mg/dl; p < 0.001, for 150 and 75 mg of alirocumab, respectively) which was also confirmed in multivariable analysis (OR = 1.10; 95% CI: 1.07-1.13).

Conclusions

Despite larger unmet needs and regional disparities in LDL-C targets achievement in CEE countries, more physicians in this region tend to use the higher dose of alirocumab, they are more prone to increase the dose, which is associated with a higher proportion of patients reaching LDL-C goals. The only factor that significantly influences decision whether to increase or decrease the dose of alirocumab is LDL-C level.

The prevalence of symptoms and its correlation with sex in polish COVID-19 adult patients: Cross-sectional online open survey

Background

The understanding and treatment of COVID-19 has improved rapidly since December 2019 when SARS-CoV-2 was sequenced. However most papers on its symptomatology focus on hospitalized patients and address only a limited number of major presentations. Although differences depending on sex of COVID-19 patients have been previously confirmed (higher ICU admission and higher death rate for men), no publication has focused on sex-related differences in COVID-19 symptomatology.

Objective

The aim of the study was to present a reliable list of COVID-19 symptoms and identify any differences in symptom prevalence depending on sex.

Methods

A sample of Polish patients suffering from COVID-19 were surveyed using a cross-sectional anonymous online survey in Polish available on a web-based surveying platform (Survey Monkey). The survey included 20 questions asking about COVID-19 symptoms, days of occurrence (from day 1 until day 14 and “15 days or more”) and patient characteristics including sex, age, height, weight, place of residence and type of therapy received during COVID-19. The survey was made available during the third COVID-19 wave in Poland. The link to the survey was distributed across social networks. Participation was open to anyone willing, without any incentives. The data was analyzed statistically.

Results

Survey responses were collected from 2,408 participants (56.9% women) aged 18–90 (42 ± 12), 84.7% living in cities, who took part in the study between December 2020 and February 2021. Out of 54 predefined symptoms, the three most prevalent were fatigue (reported by 87.61% respondents), anosmia (73.74%) and headache (69.89%). Women were found to be more symptomatic than men, 31 symptoms occurred more often in women (including anosmia, headache and myalgias, p &lt; 0.05). Subfebrility, fever and hemoptysis were more prevalent in men. Twelve symptoms (incl. hypothermia, sneezing and nausea) lasted longer in women than men (p &lt; 0.05). Fatigue, cough, nasal dryness, xerostomia and polydipsia were the longest lasting symptoms of COVID-19 (lasted over 14 days).

Conclusion

Our study presents a wide range of symptoms, which may enable better recognition of COVID-19, especially in an outpatient setting. Understanding these differences in the symptomatology of community and hospitalized patients may help diagnose and treat patients faster and more accurately. Our findings also confirmed differences in symptomatology of COVID-19 between men and women, which may lay the foundation for a better understanding of the different courses of this disease in the sexes. Further studies are necessary to understand whether a different presentation correlates with a different outcome.

Independent predictors of long-COVID in patients without comorbidities. Data from the Polish long-COVID cardiovascular (PoLoCOV-CVD) study

 

Coronavirus disease 2019 (COVID-19) is a serious respiratory disease that results from infection with a newly discovered coronavirus (SARS-COV-2). Patients recovering from SARS-COV2 infection complain of persisting symptoms which may lead to chronic fatigue syndrome and as well as many other complications. The vast majority of COVID-19 patients remaining in isolation/quarantine, due to the mild course of the disease, do not require hospitalization. There are many studies describing the course and complications of patients hospitalized due to COVID-19. There is little published data on how nonhospitalized patients get sick and what are the early and late complications of SARS-CoV-2 infection. Little is also known about Long-COVID (LC) in patients without comorbidities. Therefore, the aim of our analysis was to assess the predictors of long-lasting symptoms in patients without comorbidities suffering from COVID-19.

Methods

Patients ≥18 years of age diagnosed with COVID-19, were examined after full recovery (resolution of clinical symptoms, minimum 14 days after last symptoms). Patient information, course of the disease with symptoms, post-COVID-19 complaints were collected within 4–8 weeks after the COVID-19 recovery. We followed patients for at least 3 months. Patients were ordered the following tests: 12-lead ECG, 24-hour Holter ECG monitoring, 24-hour Holter blood pressure monitoring, Echocardiographic of the Heart assessment, Biochemical tests: lipid profile, glucose or glycosylated hemoglobin level, D-dimers. In patients with indications, the following were additionally performed: Magnetic resonance imaging of the heart, Computed tomography angiography (CTA) of pulmonary vessels, Angio CT of coronary vessels or other diagnostic tests.

Results

We identified 701 consecutive patients without comorbidities of whom 488 pts completed 3 month follow-up. Comparisons were made between LC group (n=218) and non-LC group (n=270). The demographic and laboratory characteristics of the studied group are presented in Table 1. Patients with severe course of acute phase of COVID-19 developed LC more often (72 vs. 28%, p<0.001). Significant differences regarding sex, weight, height, body mass index were observed. Patients with LC more often presented with dyspnoea, significant fatigue, chest pain, leg muscle pain, headache, arthralgia and chills. No statistically significant difference was observed regarding laboratory tests, 24-hour systolic and diastolic BP and echocardiographic parameters. LC group had higher 24-hour heart rate (77 [72–83] vs. 75 [70–81], p=0.021). Multivariate regression analysis showed that LC patients had higher BMI (odds ratio 1.057, 95% confidence intervals 1.016–1.100) and almost twice as often had a severe course (1.736, 1.071–2.814) and presented with arthralgia in the acute phase (1.901, 1.225–2.950).

Conclusions

Severe course of COVID-19, BMI, and arthralgia are independently related to long-COVID in patients without comorbidities.

Funding Acknowledgement

Type of funding sources: None.

Post-COVID-19 cardiovascular complications and their association with clinical characteristics, symptoms and comorbidities – the LATE-COVID study

Background

Among many complications of coronavirus disease 2019 (COVID-19) there is a wide range of cardiovascular (CV) problems ranging from mild to severe ones. Even asymptomatic patients and those with mild course of COVID-19 may develop severe CV complications. Factors leading to such state have not been extensively studied so far.

Purpose

We aimed to assess which factors were linked to the severe complications of COVID-19.

Methods

We included 200 consecutive patients admitted to the Department of Cardiology and Adult Congenital Heart Diseases of the Polish Mother's Memorial Research Institute (PMMHRI) due to post-Covid cardiovascular complications. SARS-CoV2 infection was confirmed with real-life PCR testing. Laboratory tests, 24-hour ECG monitoring and echocardiography were performed in all patients from the investigated group. For the purposes of our study severe complications were defined as: myocarditis, a decrease of ejection fraction &gt;10% from the pre-disease value, thromboembolic complications, angina pectoris requiring myocardial revascularization and the new onset of atrial fibrillation of supraventricular tachycardia. Some patients presented more than one of the above. Statistical analysis was performed using the software Statistica v.13 (TIBCO Software Inc., Palo Alto, CA, USA). Data were presented as mean ±SD or median (25th-75th percentile) for continuous variables and as proportions for categorical variables. Comparisons between groups were performed using Student's t-test for independent variables and the Mann-Whitney U test or χ2 test with Yates's correction, as appropriate. For all calculations p-values &lt;0.05 were considered statistically significant.

Results

Finally, we included 200 consecutive patients (aged 54±16 years, 76 males – 38%), hospitalized for COVID-19 complications after a median 3 (2–6) months following the acute phase of infection. On admission patients presented with dyspnea (23%), impairment of exercise tolerance (47%), chest pain (32%), increase in blood pressure (29%), palpitations (25%), weight loss (13%), brain fog (6%), general malaise (11%), headache (5%), limb pain (13%), swelling (14%). Severe complications of COVID-19 were diagnosed in 31 patients (16%).Taking into consideration symptoms, the presence of severe COVID-19 complications was significantly associated with dyspnoea and deterioration of exercise tolerance. In comparison to patients with mild complications, severe ones were linked to age (the older patients, the higher risk), previous history of heart failure and diabetes mellitus. We did not observe statistically significant differences in severity of complications depending on smoking status (Tables 1 and 2).

Conclusions

Previous history of heart failure and diabetes mellitus as well as symptoms (dyspnoea and deterioration of exercise tolerance) along with older age are related to more severe complications following COVID-19.

Funding Acknowledgement

Type of funding sources: None.

Statin therapy in children with familial hypercholesterolemia: a meta-analysis

Background

Familial hypercholesterolemia (FH) is a genetic disorder that may develop serious vascular damage leading to a high risk of the development of premature of cardiovascular disease (CVD).

Purpose

The aim of this meta-analysis was to evaluate the efficacy of statins on lipid profile in children patients with diagnosed FH.

Methods

We systematically searched selected electronic databases from inception until 15th March 2022. Main endpoints were lipid profile: total cholesterol (TC), triglycerides (TG), low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C) and apolipoprotein B (Apo-B), lipoprotein(a) (Lp(a)). Random effects mean reduction were used to evaluate the efficacy of statins.

Results

Eight randomized controlled trial (RCTs) with a total of 1025 children patients with FH (statins n=529) were included in the meta-analysis. At mean follow-up was 10.4 months. We showed that in the group of children treated with statins, compared to control, higher mean TC reduction −1.95 mmol/L (−75 mg/dL) [95% CI, −1.36 to −2.54; p&lt;0.001], TG reduction −0.13 mmol/L (−11.5 mg/dL) [−0.04 to −0.23; p&lt;0.001], and LDL-C reduction −1.94 mmol/L (−75 mg/dL) [−1.43 to −2.45; p&lt;0.001] were observed with significantly higher increase of the mean HDL-C, 0.37 mmol/L (14.3 mg/dL) [0.04 to 0.69; p=0.03] (Figure 1). In addition, the statins significantly reduced Apo-B [−0.50 g/L; p&lt;0.001] and did not significantly affect Lp(a) [0.13 mg/dL; p=0.87] in statins group (Figure 2).

Conclusions

The results of our meta-analysis clearly showed that children treated with statin therapy had significantly improved lipid profile with lack of effect on Lp(a). This data might help to improve statin therapy in FH children, which is highly underused worldwide.

Funding Acknowledgement

Type of funding sources: None.

Effect of the Renin-Angiotensin System Inhibitors on Inflammatory Markers: A Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVE

To synthesize more conclusive evidence on the anti-inflammatory effects of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs).

METHODS

PubMed, Scopus, and Embase were searched from inception until March 1, 2021. We included randomized controlled trials (RCTs) that assessed the effect of ACEIs or ARBs, compared with placebo, on any of the following markers: C-reactive protein (CRP), interleukin 6 (IL-6), or tumor necrosis factor α (TNF-α). Mean changes in the levels of these markers were pooled as a weighted mean difference (WMD) with a 95% CI.

RESULTS

Thirty-two RCTs (n=3489 patients) were included in the final analysis. Overall pooled analysis suggested that ACEIs significantly reduced plasma levels of CRP (WMD, -0.54 [95% CI, -0.88 to -0.21]; P=.002; I²=96%), IL-6 (WMD, -0.84 [95% CI, -1.03 to -0.64]; P<.001; I²=0%), and TNF-α (WMD, -12.75 [95% CI, -17.20 to -8.29]; P<.001; I²=99%). Moreover, ARBs showed a significant reduction only in IL-6 (WMD, -1.34 [95% CI, -2.65 to -0.04]; P=.04; I²=85%) and did not significantly affect CRP (P=.15) or TNF-α (P=.97) levels. The lowering effect of ACEIs on CRP levels remained significant with enalapril (P=.006) and perindopril (P=.01) as well as with a treatment duration of less than 24 weeks (WMD, -0.67 [95% CI, -1.07 to -0.27]; P=.001; I²=94%) and in patients with coronary artery disease (WMD, -0.75 [95% CI, -1.17 to -0.33]; P<.001; I²=96%).

CONCLUSION

Based on this meta-analysis, ACEIs showed a beneficial lowering effect on CRP, IL-6, and TNF-α, whereas ARBs were effective as a class in reduction of IL-6 only.

Effects of Implementing Personalized Health Education in Ambulatory Care on Cardiovascular Risk Factors, Compliance and Satisfaction with Treatment

Aim and Methods: Data from the CARDIOPLUS study (a prospective, multicenter, non-interventional study, which was conducted among patients and physicians from ambulatory patient care in Poland) were used to assess whether primary care behavioral counseling interventions to improve diet, increase physical activity, stop smoking and reduce alcohol consumption improve outcomes associated with cardiovascular (CVD) risk factors, metabolic parameters, compliance and satisfaction with treatment in adults. The study was carried out throughout Poland in the period from July to December 2019. Results: The study included 8667 patients—49% women and 51% men aged (63 ± 11 years)—and 862 physician-researchers. At the 3-month follow-up, there was a significant reduction in body weight (p = 0.008); reduction of peripheral arterial pressure, both systolic (p < 0.001) and diastolic (p < 0.001); reduction in total cholesterol levels (p < 0.001), triglycerides (p < 0.001), and LDL cholesterol (p < 0.001). The percentage of respondents who fully complied with the doctor’s recommendations increased significantly. The respondents assessed their own satisfaction with the implemented treatment as higher (by about 20%). Conclusions: As a result of pro-health education in the field of lifestyle modifications, a significant reduction of risk factors for cardiovascular diseases, as well as improved compliance and satisfaction with pharmacological treatment, was observed. Thus, appropriate personalized advice on lifestyle habits should be given to each examinee in a positive, systematic way following the periodic health check-ups in order to reduce the person’s risk and improve the effectiveness of the treatment.

Identification of New Copy Number Variation and the Evaluation of a CNV Detection Tool for NGS Panel Data in Polish Familial Hypercholesterolemia Patients

Familial hypercholesterolemia (FH) is an inherited, autosomal dominant metabolic disorder mostly associated with disease-causing variant in LDLR, APOB or PCSK9. Although the dominant changes are small-scale missense, frameshift and splicing variants, approximately 10% of molecularly defined FH cases are due to copy number variations (CNVs). The first-line strategy is to identify possible pathogenic SNVs (single nucleotide variants) using multiple PCR, Sanger sequencing, or with more comprehensive approaches, such as NGS (next-generation sequencing), WES (whole-exome sequencing) or WGS (whole-genome sequencing). The gold standard for CNV detection in genetic diagnostics are MLPA (multiplex ligation-dependent amplification) or aCGH (array-based comparative genome hybridization). However, faster and simpler analyses are needed. Therefore, it has been proposed that NGS data can be searched to analyze CNV variants. The aim of the study was to identify novel CNV changes in FH patients without detected pathogenic SNVs using targeted sequencing and evaluation of CNV calling tool (DECoN) working on gene panel NGS data; the study also assesses its suitability as a screening step in genetic diagnostics. A group of 136 adult and child patients were recruited for the present study. The inclusion criteria comprised at least “possible FH” according to the Simon Broome diagnostic criteria in children and the DLCN (Dutch Lipid Clinical Network) criteria in adults. NGS analysis revealed potentially pathogenic SNVs in 57 patients. Thirty selected patients without a positive finding from NGS were subjected to MLPA analysis; ten of these revealed possibly pathogenic CNVs. Nine patients were found to harbor exons 4−8 duplication, two harbored exons 6−8 deletion and one demonstrated exon 9−10 deletion in LDLR. To test the DECoN program, the whole study group was referred for bioinformatic analysis. The DECoN program detected duplication of exons 4−8 in the LDLR gene in two patients, whose genetic analysis was stopped after the NGS step. The integration of the two methods proved to be particularly valuable in a five-year-old girl presenting with extreme hypercholesterolemia, with both a pathogenic missense variant (c.1747C>T) and exons 9−10 deletion in LDLR. This is the first report of a heterozygous deletion of exons 9 and 10 co-occurring with SNV. Our results suggest that the NGS-based approach has the potential to identify large-scale variation in the LDLR gene and could be further applied to extend CNV screening in other FH-related genes. Nevertheless, the outcomes from the bioinformatic approach still need to be confirmed by MLPA; hence, the latter remains the reference method for assessing CNV in FH patients.

Dyslipidemia Management in Pregnancy: Why Is It not Covered in the Guidelines?

PURPOSE OF REVIEW

Despite the elevation of lipid values during pregnancy is mostly physiological, evidence suggest that it may be associated with adverse events. This article reviews the characteristics of lipid disorders and the possible management with dyslipidemia in pregnant women.

RECENT FINDINGS

Among many available groups of lipid-lowering drugs, only bile acid sequestrants are approved for the treatment of dyslipidemia during pregnancy. Ezetimibe and fenofibrate might be considered if benefits outweigh the potential risk. Statins are still contraindicated due to the results mainly from animal studies and series of human cases. However, recent systematic reviews and meta-analyses showed that their use may not be detrimental, and in some selected cases may be beneficial. Especially, in some groups of pregnant patients with very high cardiovascular risk-those already after an event, or with established cardiovascular disease, with homozygous familial hypercholesterolemia; in such cases the final decision should weight the potential risk of discontinuation of therapy. Finally, we need to wait for the data with new drugs, including PCSK9 inhibitors and especially inclisiran, which (still hypothetically) might be a very interesting option as it may be used just before the pregnancy and immediately after with the duration of about 9 months between injections. The decisions on lipid-lowering therapy in pregnant patients should be individualized. Despite design and ethical difficulties with such studies, further investigations on dyslipidemia treatment during pregnancy are highly awaited.

Biochemical and cardiovascular predictors of PIMS-TS risk in children after COVID-19 recovery: preliminary results of the LATE-COVID-Kids Study

INTRODUCTION

We aimed to characterize biochemical and cardiovascular predictors of the paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) risk based on the data from the LATE-COVID-Kids study.

METHODS

148 consecutive COVID-19 convalescents hospitalized for the clinical evaluation after the acute phase of COVID-19 were classified into two groups related to symptoms: 33 children finally diagnosed with PIMS-TS and 115 children without PIMS-TS (control group).

RESULTS

PIMS-TS children were significantly younger (6.79 ±4.57 vs. 9.10 ±4.94 years). After adjustment, in comparison to those without, PIMS-TS children had a higher level of antithrombin III (111 ±9.30 vs. 105 ±11.4), higher heart rate (HR)/min (100 (89.0-111) vs. 90 (79.7-100)) and sinus rhythm (p = 0.03) but lower PQ interval (p = 0.02) on admission to hospital. The lymphocytes (absolute count and percentage) were significantly higher in children with PIMS-TS, and the opposite results were obtained for IgA and neutrophils. Furthermore, children with PIMS-TS had a higher level of thyroid stimulating hormone (2.76 (2.16-4.18) vs. 2.36 (1.73-2.83)) and red cell distribution width (p < 0.005) compared to those without.

CONCLUSIONS

It is the first data on the possible predictors of PIMS-TS risk in the Long-COVID period. These results need to be further validated to next create the PIMS SCORE algorithm, which might enable the effective prediction of children with the risk of PIMS-TS occurrence after COVID-19 recovery.

Design and rationale of a nationwide screening analysis from the LIPIDOGRAM2015 and LIPIDOGEN2015 studies

INTRODUCTION

Cardiovascular disease (CVD) is a major cause of morbidity and mortality throughout the world. The LIPIDOGRAM2015 study was performed to estimate the prevalence of risk factors for atherosclerotic diseases as well as cardiovascular and related disorders in the primary care setting in Poland. The LIPIDOGEN2015 sub-study was designed to include a random cohort of patients in order to analyse parameters related to lipid metabolism, oxidative stress, inflammatory responses, autoimmune disorders, and gene variants that confer susceptibility to cardiometabolic and atherosclerotic diseases.

MATERIAL AND METHODS

The recruitment was carried out by 438 primary care physicians in Poland. The expected number of patients recruited for the LIPIDOGRAM2015 study was 13,000-14,000 with 13-15% (1700-2000) also participating in the LIPIDOGEN2015 sub-study. Each patient had to complete a questionnaire concerning medical and family history, concomitant diseases, and pharmacotherapy. Anthropometric measurements were performed at the doctor's office. For the LIPIDOGEN2015 sub-study, saliva samples for DNA isolation and blood samples for measurement of glycated haemoglobin, oxidative stress parameters, autoantibody levels, and inflammatory cytokine profile and apolipoprotein profile were collected. Follow-up data will be obtained from the National Health Fund in Poland.

RESULTS

The LIPIDOGRAM2015 and LIPIDOGEN2015 study cohort reflects the prevalence of cardiovascular risk factors and concomitant diseases, markers of oxidative stress, the presence of autoantibodies, inflammatory cytokine profile, and apolipoprotein profile, as well as genetic variants potentially conferring susceptibility to cardiometabolic and atherosclerotic diseases.

CONCLUSIONS

This study presents the prevalence of different CV risk factors, with special emphasis on lipid disorders, and it assesses the relationship between inflammation, oxidative stress, and mutations in genes encoding proteins regulating lipid metabolism, as well as genes conferring susceptibility to cardiovascular, cardiometabolic, and related diseases.

Patient after correction Taussig-Bing anomaly with severe neo-aortic regurgitation after sudden cardiac arrest

The Taussig-Bing anomaly is a rare cyanotic congenital heart defect treated surgically in the early infancy. The preferred repair procedure is an arterial switch operation combined with ventricular septal defect closure. Despite promising long-term functional outcomes and survival benefits, neo-aortic dysfunction and arrhythmias might be relevant complications.

Global perspective of familial hypercholesterolaemia: a cross-sectional study from the EAS Familial Hypercholesterolaemia Studies Collaboration (FHSC)

BACKGROUND

The European Atherosclerosis Society Familial Hypercholesterolaemia Studies Collaboration (FHSC) global registry provides a platform for the global surveillance of familial hypercholesterolaemia through harmonisation and pooling of multinational data. In this study, we aimed to characterise the adult population with heterozygous familial hypercholesterolaemia and described how it is detected and managed globally.

METHODS

Using FHSC global registry data, we did a cross-sectional assessment of adults (aged 18 years or older) with a clinical or genetic diagnosis of probable or definite heterozygous familial hypercholesterolaemia at the time they were entered into the registries. Data were assessed overall and by WHO regions, sex, and index versus non-index cases.

FINDINGS

Of the 61 612 individuals in the registry, 42 167 adults (21 999 [53·6%] women) from 56 countries were included in the study. Of these, 31 798 (75·4%) were diagnosed with the Dutch Lipid Clinic Network criteria, and 35 490 (84·2%) were from the WHO region of Europe. Median age of participants at entry in the registry was 46·2 years (IQR 34·3-58·0); median age at diagnosis of familial hypercholesterolaemia was 44·4 years (32·5-56·5), with 40·2% of participants younger than 40 years when diagnosed. Prevalence of cardiovascular risk factors increased progressively with age and varied by WHO region. Prevalence of coronary disease was 17·4% (2·1% for stroke and 5·2% for peripheral artery disease), increasing with concentrations of untreated LDL cholesterol, and was about two times lower in women than in men. Among patients receiving lipid-lowering medications, 16 803 (81·1%) were receiving statins and 3691 (21·2%) were on combination therapy, with greater use of more potent lipid-lowering medication in men than in women. Median LDL cholesterol was 5·43 mmol/L (IQR 4·32-6·72) among patients not taking lipid-lowering medications and 4·23 mmol/L (3·20-5·66) among those taking them. Among patients taking lipid-lowering medications, 2·7% had LDL cholesterol lower than 1·8 mmol/L; the use of combination therapy, particularly with three drugs and with proprotein convertase subtilisin-kexin type 9 inhibitors, was associated with a higher proportion and greater odds of having LDL cholesterol lower than 1·8 mmol/L. Compared with index cases, patients who were non-index cases were younger, with lower LDL cholesterol and lower prevalence of cardiovascular risk factors and cardiovascular diseases (all p<0·001).

INTERPRETATION

Familial hypercholesterolaemia is diagnosed late. Guideline-recommended LDL cholesterol concentrations are infrequently achieved with single-drug therapy. Cardiovascular risk factors and presence of coronary disease were lower among non-index cases, who were diagnosed earlier. Earlier detection and greater use of combination therapies are required to reduce the global burden of familial hypercholesterolaemia.

FUNDING

Pfizer, Amgen, Merck Sharp & Dohme, Sanofi-Aventis, Daiichi Sankyo, and Regeneron.

COVID-19 and lipids. The role of lipid disorders and statin use in the prognosis of patients with SARS-CoV-2 infection

The global coronavirus disease 2019 (COVID-19) pandemic caused by the SARS-CoV-2 coronavirus started in March 2020. The conclusions from numerous studies indicate that people with comorbidities, such as arterial hypertension, diabetes, obesity, underlying cardiovascular disease, are particularly vulnerable to the severe course of COVID-19. The available data also suggest that patients with dyslipidemia, the most common risk factor of cardiovascular diseases, are also at greater risk of severe course of COVID-19. On the other hand, it has been shown that COVID-19 infection has an influence on lipid profile leading to dyslipidemia, which might require appropriate treatment. Owing to antiviral, anti-inflammatory, immunomodulatory, and cardioprotective activity, statin therapy has been considered as valuable tool to improve COVID-19 outcomes. Numerous observational studies have shown potential beneficial effects of lipid-lowering treatment on the course of COVID-19 with significant improved prognosis and reduced mortality.

Clinical features of familial hypercholesterolaemia in children and adults – the PMMHRI Registry

Background

Familial hypercholesterolaemia (FH) affects approximately 150,000 people in Poland. However, there are many patients still unaware of this diagnosis. On the other hand, it might lead to early cardiovascular mortality and morbidity due to the lifetime exposure to high levels of LDL-C. Therefore, increased awareness of FH is very important.

Purpose

We aimed to evaluate the clinical features of FH in children and adults based on the preliminary data from the Polish Mother's Memorial Hospital Research Institute (PMMHRI) Registry.

Methods

The registry of children and adults with FH conducted in PMMHRI (2nd largest, supra-regional hospital in Poland) was established to investigate the clinical characteristics, management and clinical outcomes data of FH patients. All consecutive patients with diagnosed (genetically and/or phenotypically) FH were included in the study.

Results

Of 103 patients with FH, there were 16 children aged 9±3 and 87 adults aged 41±16; 59% were female. The diagnosis of FH in adults was late – at the mean age of 41 years. Among children with FH, as compared with adults, the levels of highest TC and LDL-C ever were similar. However, children presented higher mean levels of total cholesterol, LDL-C and HDL-C measured at baseline visit (Table). Interestingly there was no difference in BMI between children and adults (Table). Among adults, chronic coronary syndrome was diagnosed in 11.5% patients, from which 5.7% patients had a history of myocardial infarction and 7% patients required revascularization. The prevalence of chronic coronary disease, peripheral artery disease as well as stroke in family history was definitely higher (in 44 patients – 50%, 17 patients – 20% and 22 patients – 25%, respectively). Most of adult patients at baseline visit were prescribed statins (rosuvastatin or atorvastatin). 14 patients (13.6%) declared statin intolerance, most of them complained of muscle pain, 4.6% patients reported hepatic disturbances. The frequency of statin use in children was lower – 56% children were prescribed statin, 19% declared statin intolerance with muscle pain as the side-effect of treatment. Ezetimibe, as a part of combination therapy, was taken by 29% adult patients. PCSK9 inhibitors were prescribed (within drug program) for 11.5% adult patients. Fibrates were prescribed for 13.7% adult patients, the same was for n-3 fatty acids.

Conclusions

Despite definitely younger age of FH diagnosis children present higher mean levels of LDL cholesterol than adults. Therefore, the lifetime exposure to LDL cholesterol starts at a very young age. As a result, there is a need to the earlier initiation of therapy and strict monitoring of the atherosclerosis progression. On the other hand, late diagnosis of FH in adults is an unmet need, that might be associated with poorer prognosis.

Funding Acknowledgement

Type of funding sources: None.

Biochemical and cardiovascular predictors of PIMS risk in children after COVID-19 recovery =- the results of the LATE COVID Kids study

Background

Unfortunately, the number of children with the pediatric inflammatory multisystem syndrome (PIMS) associated with previous coronavirus disease has been increasing significantly.

Purpose

The aim of the present study was to characterize biochemical and cardiovascular predictors of PIMS risk in children recovered from COVID-19 based on the data from the LATE-COVID-Kids study (NCT04799444).

Methods

131 consecutive COVID-19 convalescents (mean age: 8.89±4.91; 67 boys and 64 girls) hospitalized for the clinical evaluation after the acute phase of the COVID-19 were classified into two groups related to symptoms: 29 children finally diagnosed with PIMS and 102 children with no-PIMS. All patients had confirmed coronavirus infection based on the positive results of nucleic acid test (RT-PCR - reverse transcriptase-polymerase chain), and they were serologically tested for antibodies against SARS-CoV-2. They had detailed laboratory testing, electrocardiography, and echocardiography.

Results

The time from COVID-19 recovery was from 1 to 10 months (median 4.0 [3.00–5.00] months). Children with PIMS were significantly younger in comparison to those without (6.60±4.50 vs 9.50±4.80 years, respectively; p=0,005). In comparison to non-PIMS group, children with PIMS had higher level of antithrombin III (111±7.23 vs. 104±10.9; p=0.0015), CK-MB (29.0 [18.5–36.0] vs. 21.0 [15.0–30.7]; p=0.03) and heart rate [HR]/min (100 [89.0–112] vs. 90.0 [79.0–100]; p=0.006) but lower PQ interval (120 [110–120] vs. 130 [120–140]; p=0.023) on admission to hospital. Moreover, the immunological parameters: IgA and neutrophils were lower in children with PIMS vs. no-PIMS (0.69 [0.47–0.85] vs. 1.19 [0.71–1.50]; p=0.0001 and 37.4%±13.3 vs. 43.0±11.6; p=0.0045, respectively), but lymphocytes were significantly higher (50.6±13.6 vs. 43.7±10.9; p=0.002). Some acid-base balance parameters were higher in children following PIMS vs. no-PIMS children group: pCO2 (41.30±5.70 vs. 45.0±7.00; p=0.019), pO2 (50.1 [38.4–59.7] vs. 37.8 [27.9–49.9]; p=0.007), and O2Sat (84.2 [69.3–90.6] vs. 64.2 [44.3–82.6]; p=0.004); however, concentration of HCO3- (23.6 [22.2–24.4] vs. 24.3 [22.8–26.2]; p=0.023) was lower in group of PIMS children.

Conclusions

Based on our best knowledge, it is the first data on the possible predictors of PIMS risk in children recovered from COVID-19. We showed that children with PIMS have significantly higher levels of antithrombin III, CK-MB, HR, as well as lymphocytes, pCO2, pO2 and O2Sat on admission to hospital and lower levels of PQ interval, IgA, neutrophils and concentration of HCO3. We continue our research to confirm these results and to create the PIMS SCORE algorithm to allow prediction of children with the risk of PIMS occurrence after COVID-19 recovery.

Funding Acknowledgement

Type of funding sources: None.

Clinical Features of Familial Hypercholesterolemia in Children and Adults in EAS-FHSC Regional Center for Rare Diseases in Poland

BACKGROUND

Familial hypercholesterolemia (FH) is a genetic autosomal co-dominant metabolic disorder leading to elevated circulating concentrations of low-density lipoprotein cholesterol (LDL-C). Early development of atherosclerotic cardiovascular disease (ASCVD) is common in affected patients. We aimed to evaluate the characteristics and differences in the diagnosis and therapy of FH children and adults. Methods: All consecutive patients who were diagnosed with FH, both phenotypically and with genetic tests, were included in this analysis. All patients are a part of the European Atherosclerosis Society FH-Study Collaboration (FHSC) regional center for rare diseases at the Polish Mother's Memorial Hospital Research Institute (PMMHRI) in Lodz, Poland. Results: Of 103 patients with FH, there were 16 children (15.5%) at mean age of 9 ± 3 years and 87 adults aged 41 ± 16; 59% were female. Children presented higher mean levels of total cholesterol, LDL-C, and high-density lipoprotein cholesterol (HDL-C) measured at the baseline visit (TC 313 vs. 259 mg/dL (8.0 vs. 6.6 mmol/L), p = 0.04; LDL 247 vs. 192 mg/dL (6.3 vs. 4.9 mmol/L), p = 0.02, HDL 53 vs. 48 mg/dL (1.3 vs. 1.2 mmol/L), p = 0.009). Overall, 70% of adult patients and 56% of children were prescribed statins (rosuvastatin or atorvastatin) on admission. Combination therapy (dual or triple) was administered for 24% of adult patients. Furthermore, 13.6% of adult patients and 19% of children reported side effects of statin therapy; most of them complained of muscle pain. Only 50% of adult patients on combination therapy achieved their treatment goals. None of children achieved the treatment goal.

CONCLUSIONS

Despite a younger age of FH diagnosis, children presented with higher mean levels of LDL-C than adults. There are still urgent unmet needs concerning effective lipid-lowering therapy in FH patients, especially the need for greater use of combination therapy, which may allow LDL-C targets to be met in most of the patients.

Cardiac manifestations of COVID-19

COVID-19 is a novel viral infection caused by severe acute respiratory syndrome (SARS) beta-coronavirus. Epidemiological status changes dynamically as the pandemy is far from ending. Several complications of presented virus may be similar to those observed in other viral infections. Despite lacking data, the heart involvement may be comparable to cardiac complications observed previously in those with SARS as well as Middle East Respiratory Syndrome (MERS). In COVID-19 we observe elevated levels of cardiac biomarkers, such as natriuretic peptides, troponins, myoglobin, C-reactive protein (CRP), interleukin-2 (IL-2), interleukin-6 (IL-6) and ferritin, which is likely the result of myocardial injury. The possible mechanisms of cardiovascular injury include direct toxicity through the viral invasion of cardiac myocytes, ACE-2 receptor-mediated CV (cardiac and endothelial) injury, microvascular dysfunction and thrombosis and cytokine release syndrome (mainly IL-6 mediated). Cardiac manifestations of COVID-19 are focal or global myocardial inflammation, necrosis, ventricular dysfunction, heart failure and arrhythmia.

COVID-19 and cardiovascular complications - preliminary results of the LATE-COVID study

INTRODUCTION

Coronavirus disease 2019 (COVID-19) may affect many organs and may be responsible for numerous complications including cardiovascular problems.

METHODS

We analysed consecutive patients (n = 51) admitted to the cardiology department between 1st October 2020 and 31st January 2021 due to symptoms which might have reflected cardiovascular complications following COVID-19. We collected data concerning clinical characteristics, results of laboratory tests, echocardiography and 24-hour ambulatory ECG recording.

RESULTS

The post-COVID-19 complications appeared 1-4 months after disease recovery. Severe cardiovascular complications were observed in 27.5% of hospitalized patients. In comparison to those with mild complications, patients with severe complications had significantly higher prevalence of diabetes (36 vs. 8%; p = 0.01), decrease in ejection fraction (36% vs. 0%, p < 0.001), higher resting heart rate at admission (85 vs. 72 bpm; p < 0.001), and higher levels of C-reactive protein (p = 0.02) and troponin T (17.9 vs. 4.2 pg/ml; p = 0.01). Dyspnoea and exercise intolerance were also more frequent in patients with severe complications.

CONCLUSIONS

Diabetes, elevated level of CRP and troponin, heart rate variability parameters and worsening of left ventricular ejection fraction are related to the severity of cardiovascular complications following COVID-19 infection.

Pharmacological management of malignant hypertension

INTRODUCTION

According to current guidelines, malignant hypertension is one of the emergencies in hypertension. The definition requires the presence of bilateral retinal hemorrhages or exudates, with or without papilledema, acute heart failure and acute deterioration in renal function in severe hypertension. Patients with malignant hypertension are characterized by pronounced target organ damage, including structural and functional cardiac abnormalities and renal insufficiency.

AREAS COVERED

Knowledge of the available treatment options is extremely important as we know that we only have a limited time to reduce blood pressure. There are only four drugs dedicated to immediate blood pressure lowering in patients with malignant hypertension, including 'first-line' and alternative drugs. Our review aims to discuss all those drugs and gives practical suggestions on how to properly use them.

EXPERT COMMENTARY

The decision of which drug to use depends on numerous factors including the clinical indications, pharmacokinetics, toxicity and drug interactions. Furthermore, frequently, more than one of the recommended drugs is required for the successful lowering of the patient's blood pressure.

P1311 A rare case of asymptomatic cyst in interatrial septum longterm observation

Background

Incidental findings in echocardiography performed from other indications are not always able to explain the patient condition as well as the observed pathology. However, review of literature, helps to find the most possible explanation. We present a case study of a patient with our proposal of possible diagnosis.

Case report

28-year old female with hypothyroidism and no other concomitant diseases presented with easy fatigue. Exercise stress test was clinically and ECG negative with 12,8 METs. Transthoracic echocardiography showed normal size of heart structures with preserved systolic and diastolic function of both left and right chamber. The only abnormality was a cystic structure of 44x31x34 cm in interatrial septum which was protruding to both left and right atrium and was not affecting the blood flow with normal gradients. We did not find any signs of inflammation nor infiltration to the heart walls. There was no flow inside the cyst with the use of colour Doppler. The structure had homogenous echolucency with very thin walls and a septum inside. As we did not find any connection between the cyst and the atriums we considered it as not harmful in terms of a risk of embolization. Patient was hemodynamically stable, there was no history of neurological dysfunctions nor atrioventricular conduction disturbances. Taking into account possible diagnoses for that patient we decided to schedule the patient for follow-ups. Ten years observation period confirmed that that our approach was proper. Serial echocardiographic studies showed no change in the cyst. In this year we performed multimodality imaging with CT and MRI, which showed the same views as echocardiography.

Discussion

The most possible diagnose for our patient is a bronchogenic cyst, a very rare congenital bronchopulmonary malformation of the foregut that is usually found incidentally with mostly asymptomatic benign course. Also the localization of the cyst confirms that diagnosis. Nevertheless the final diagnosis would be possible only in histopathological study.

The differential diagnosis should include a cystic myxoma and echinococcosis. However the structure is not polycystic and seems to have homogenous echolucency. We ruled out the blood cyst because of the lack of typical localization and connection to valves.

As long as the patient remains asymptomatic surgical resection remains controversial.

P253 Patient after correction of Taussig-Bing anomaly with severe neoaortic regurgitation and after sudden cardiac arrest

The Taussig –Bing anomaly is a rare congenital heart malformation that was first described in 1949 by Helen B. Taussig and Richard J. Bing. It is characterized by the presence of a large subpulmonic ventricular septal defect (VSD) and, usually, side-by-side great vessels that arise entirely from the right ventricle. Unlike TGA with VSD, this anomaly is characterized by the presence of a bilateral conus and the absence of aortomitral continuity. Increased pulmonary blood flow leads to early onset of pulmonary vascular disease, hence repair in the early infancy period is recommended. VSD closure combined with arterial switch is currently the preferred procedure. Lecompte introduced a new surgical technique that includes extensive resection of the conal septum and direct reimplantation of the pulmonary trunk on the superior margin of the right ventricular infundibulotomy.

We present case of 18-year-old male patient with Taussig-Bing anomaly after pulmonary artery binding and closure of ductus arteriosus when one year old and after anatomical Jatene correction with modified Lacompte procedure at the age of two years. The patient was admitted to our Department in October 2018 after episode of sudden cardiac arrest in the mechanism of ventricular fibrillation. Echocardiographic examination revealed preserved systolic function of both ventricles (LVEF 62%, TAPSE 25 mm, RV S’ 13cm/s) without contractility disturbances. The enlarged and hypertrophic left ventricle consists of the primary cavity connecting by VSD (size 39 mm) with a fragment of the right ventricle separated from the rest of the right ventricle by a patch with Gore-Tex acting as a ventricular septum - without any leakage features (Figure 1A and 1B). We noticed also enlarged left atrium, increased diameter of neoaorty bulb (50 mm), severe neoaortic regurgitation (AV max: 1,85 m/s, ERO-70, VC-8mm, PHT 327 ms) (Figure 1C), moderate mitral regurgitation (type I according Carpentier) (Figure1D). On 8.01.2019 a subcutaneous ICD Boston Scientific Emblem with a subcutaneous defibrillation electrode was implanted. In performed spiroergometry decreased peak oxygen consumption (2,24 ml/min/kg), the study was stopped because of fatique, assessed expiratory exchange ratio, and episode of nsVT. After decision of Heart Team the patient is qualified for surgical treatment of valve defects.

Abstract P253 Figure 1

P1452 A rare case of embolic blindness in an adult patient with univentricular heart after fontan operation

Background

Thromboembolic complications following Fontan procedure are one of the major causes of mortality and morbidity among patients with univentricular heart. We may classify thromboembolic complications into two groups: systemic- and nonsystemic. We present a case of a patient with a manifestation of both.

Case report

24-year old female, foreign student was admitted to Ophthalmology Department due to sudden blindness of the left eye. Performed studies revealed embolus in the left central retinal artery. Because the patient had the history of congenital heart defect she was referred to our department. Analysis of medical documentation showed that the patient has combined congenital heart defect including right ventricle hypoplasia, tricuspid atresia, pulmonic stenosis, ventricular septal defect, atrial septal defect and persistent ductus arteriosus. She had a history of two surgeries: modified left-side Blalock-Tausing connection (in 4th month of life) and total cavo-pulmonary connection with the closure of Blalock-Tausing and excision of interatrial septum (in 2,5 year of life). On admission she presented with left-eye blindness. She had no dyspnoea or palpitations. However she reported very severe migraines from a few days preceding the admission to hospital. Echocardiography revealed tricuspid atresia, hypoplastic right ventricle, preserved systolic and diastolic function of left ventricle, atrial septal defect with no restriction. We observed enlarged diameter of vena cava inferior with no respirophasic variations and massive thrombus in inside with very low flow. The connection between inferior vena cava and right pulmonary artery was working properly with no visible fenestration. We also observed a winding vessel between ascending aorta and truncus pulmonalis/pulmonary artery with continuous flow of blood from left to right side. Computer tomography confirmed the diagnosis of massive thrombosis of vena cava inferior. Patient had anticoagulation started. Two days later we the flow in inferior vena cava returned – we did not observe any thrombus. Patient was referred to catheterization and had chronic anticoagulation initiated.

Three months follow-up revealed no changes in clinical condition of a patient.

Discussion

The palliative Fontan operation predispose to the increased risk of thromboembolic complication. Despite the risk factors of such complications have been identified, there are no guidelines about prophylactic anticoagulation in that group of patients. As a result, chronic anticoagulation is initiated in patients who have other indications e.g. atrial fibrillation. It seems that it would be beneficial to define the group of patients after Fontan procedure with indications to chronic anticoagulation therapy despite arrhythmias.

Renal denervation--hypes and hopes

Catheter-based renal denervation (RDN) is a novel invasive approach in the treatment of resistant hypertension. It is considered a minimally invasive and safe procedure which, as shown by initial experimental and clinical trials, is able not only to reduce blood pressure but also to modify its risk factors by modulation of autonomic nervous system. Recently published results of a randomized Symplicity HTN-3 trial, which failed to demonstrate RDN-induced reduction of blood pressure at six months, decreased the initial enthusiasm regarding RDN and raised a question about real efficacy of this procedure. Nevertheless, still there are some other conditions characterized by increased sympathetic tone such as heart failure, atrial fibrillation, or ventricular arrhythmias that may benefit from RDN. Furthermore, novel therapeutical approach toward RDN using adapted electrophysiological or new specially designed electrodes may improve effectiveness of RDN procedure.

Short-term ECG recordings for heart rate assessment in patients with chronic atrial fibrillation

INTRODUCTION

There is no consensus on the length of ECG tracing that should be recorded to represent adequate rate control in patients with atrial fibrillation (AFib). The purpose of the study was to examine whether heart rate measurements based on short-term ECGs recorded at different periods of the day may correspond to the mean heart rate and rate irregularity analyzed from standard 24-hour Holter monitoring.

MATERIAL AND METHODS

The study enrolled 50 consecutive patients with chronic AFib who underwent 24-hour Holter monitoring. Mean heart rate (mHR) and the coefficient of irregularity (CI) were assessed from 5- and 60-minute intervals of Holter recordings in different periods of the day.

RESULTS

The highest correlation in mean heart rate interval within 24 h was found during a 6-hour sample and in the periods 11.00 AM-12.00 PM, 12 PM-1.00 PM, and 1.00 PM-2.00 PM. With respect to irregularity, only the CI measurements based on a 6-hour interval (7.00 AM-1.00 AM) show a correlation > 0.08 compared to data from the 24-hour recording.

CONCLUSIONS

Only long-term (6-hour) recordings provide a high correlation within 24 h in mean heart rate interval and coefficient of irregularity. It seems that the mean heart rate interval in 1-hour periods between 11 AM and 2 PM might be predictive for 24-hour data. Short time recordings of the coefficient of irregularity of heart rate in AFib patients at this moment are not useful in clinical practice for long-term prognosis of ventricular irregularity.

Endocardial Lead Extraction in the Polish Registry - clinical practice versus current Heart Rhythm Society consensus

INTRODUCTION

Over the last 10 years, there has been an increasing number of patients with pacemaker (PM) and cardioverter-defibrillator (ICD). This study is a retrospective analysis of indications for endocardial pacemaker and ICD lead extractions between 2003 and 2009 based on the experience of three Polish Referral Lead Extraction Centers.

MATERIAL AND METHODS

Since 2003, the authors have consecutively retrospectively collected all cases and entered the information in the database. All patients which had indication for lead extraction according to Heart Rhythm Society Guidelines were included to final analyze. Between 2003 and 2005, the data were analyzed together. Since 2006, data have been collected and analyzed annually.

RESULTS

In each year, a significant increase in lead extraction was observed. The main indications for LE were infections in 52.4% of patients. Nonfunctioning lead extraction constituted the second group of indications for LE in 29.7% of patients. During the registry period, the percentage of class I indications decreased from 80% in 2006 to only 47% in 2009. On the other hand, increasingly more leads were removed because of class 2, especially class 2b. In 2009, 40% of leads were extracted due to class 2b.

CONCLUSIONS

Polish Registry of Endocardial Lead Extraction 2003-2009, shows an increasing frequency of lead extraction. The main indication for LE is infection: systemic and pocket. An increase in class 2, especially 2b, LE indication in every center during the study period was found.

An acupuncture needle remaining in a lung for 17 years: case study and review

The case of a 67-year-old patient with an acupuncture needle remaining in his left lung is described. This foreign body was a remnant of a procedure performed by a doctor 17 years previously for osteoarthritic back pain. On the basis of this case, a review was performed of literature available in the PubMed database dealing with acupuncture needles remaining in a patient's body. A total of 25 articles were found. The articles describe needles found in the bladder, shoulder girdle, spinal cord, right ventricle, L5 nerve root, medulla oblongata, skin, carpal tunnel, nuchal and occipital area, calf and paraspinal muscle. Migration of needle fragments to the liver, pancreas, stomach, colon, breast, kidney, muscles, and spinal cord has been reported in the literature. In cases where patients were operated on, the needles were removed without subsequent complications and the patients recovered fully.

Clinical and electrocardiographic covariates of deceleration capacity in patients with ST-segment elevation myocardial infarction

BACKGROUND

Deceleration capacity (DC) is a novel electrocardiography (ECG) parameter characterizing the overall capacity of slowing down the heart rate. The aim of this study was to evaluate clinical and ECG covariates of DC in patients with the first episode of ST-segment elevation myocardial infarction (STEMI) treated with primary angioplasty.

METHODS

Deceleration capacity, heart rate variability (HRV) and heart rate turbulence (HRT) were assessed from 24-hour ECG Holter recordings in 70 patients (66 male, mean age 57 years) with STEMI. Deceleration capacity was evaluated as continuous or dichotomized (< or = 4.5 vs. > 4.5 ms) variable.

RESULTS

The median value of DC was 5.12 ms. Thirty patients (43%) had abnormal DC ( < or = 4.5 ms). The abnormal DC was more common in female, older and hypertensive patients. Although DC was not associated with either STEMI localization or left ventricular ejection fraction, it was significantly correlated with mean heart rate, standard HRV indices and HRT slope. Multivariate logistic regression showed that hypertension (OR = 3.23, 95% CI = 1.1-9.9, p = 0.039) and mean heart rate > 70 beats/minute (OR = 6.05, 95% CI = 2.0-18.4, p = 0.001) were independently associated with abnormal DC.

CONCLUSIONS

Deceleration capacity in patients with the first STEMI treated with primary angioplasty is influenced by age, gender, hypertension and heart rate, but not the location of myocardial infarction or left ventricular ejection fraction. Correlation between DC and HRV indices suggests that DC is related to autonomic modulation of heart rate.